Clinical Scholarship

Conceptual Model of Health-Related Quality of Life

Carol Estwing Ferrans, Julie Johnson Zerwic, Jo Ellen Wilbur, Janet L. Larson

Purpose: To revise the Wilson and Cleary model of health-related quality of life (HRQoL),
with suggestions for applying each of the components, and to facilitate the use of HRQoL
in nursing and health care.
Organizing Construct: HRQoL, based on relevant literature over the past 20 years.
Methods: The original model was revised in three substantive ways: (a) indicating that bio-
logical function is influenced by characteristics of both individuals and environments; (b)
deleting nonmedical factors; and (c) deleting the labels on the arrows that tend to restrict
characterization of the relationships.
Findings: Theoretical background is provided for each of the major components of the model,
and examples of instruments to measure them, were added.
Conclusions: In quality-of-life research, the current challenge is to devise models to clarify
the elements of health-related quality of life (HRQOL) and the causal relationships among
them. This revision of Wilson and Cleary’s model includes a taxonomy of the variables that
often have been used to measure HRQoL. This revision should be useful in research and
clinical practice.

JOURNAL OF NURSING SCHOLARSHIP, 2005; 37:4, 336-342.

C 2005 SIGMA THETA TAU INTERNATIONAL.

[Key words: quality of life, health-related quality of life, causal models, theory
development, health care, research applications ]

* * *

O
ver the past 30 years, evaluation of quality of The current need is for causal models that clearly indi-
life has become increasingly important in health cate the elements of HRQoL and their determinants. To
care. Quality-of-life research has increased in date, most models have been focused on the identification
methodologic rigor and sophistication. Nevertheless, of domains. These efforts have helped to define the scope
progress has been hindered by the fact that term “quality of of quality of life by making clear that the term refers to
life” has been used to mean a variety of different things, such all of life, and not just physical health status. However,
as health status, physical functioning, symptoms, psychoso- identifying domains is not enough. For example, the term
cial adjustment, well-being, life satisfaction, and happiness. “physical domain” can refer to pathophysiological changes,
As a consequence, comparing findings across studies to draw symptoms, functional deficits, or perceived health status. A
conclusions or make application in practice is difficult. causal model with clear distinctions between the most com-
To help solve the problem, the term “health-related qual- mon approaches used to assess HRQoL was developed by
ity of life” (HRQoL) was introduced. This term was in- Wilson and Cleary (1995). In this paper we present (a) the
tended to narrow the focus to the effects of health, ill- theoretical grounding of characteristics of individual and
ness, and treatment on quality of life. This term excludes environment, (b) a revised version of their model, and (c)
aspects of quality of life that are not related to health, suggestions for applying each of the components in nursing
such as cultural, political, or societal attributes. Examples and health care.
are the quality of the environment, public safety, educa-
Carol Estwing Ferrans, RN, PhD, FAAN, Alpha Lambda, Professor; Julie
tion, standard of living, transportation, political freedom, Johnson Zerwic, RN, PhD, Alpha Lambda, Associate Professor; Jo Ellen
or cultural amenities. Unfortunately, the distinction between Wilbur, RN, PhD, FAAN, Alpha Lambda, Professor and Associate Dean for
health-related and nonhealth-related quality of life cannot Research; Janet L. Larson, RN, PhD, FAAN, Alpha Lambda, Professor and
always be clearly made. For example, air pollution con- Department Head; all at University of Illinois at Chicago, College of Nursing,
Chicago, IL. This study was funded in part by the Center for Reducing Risks
tributes to chronic respiratory disease, and long dark win- in Vulnerable Population, NIH/NINR P30-NR09014, University of Illinois at
ters contribute to seasonal affective disorder. In addition, in Chicago. Correspondence to Dr. Ferrans, University of Illinois at Chicago,
chronic illness almost all areas of life are affected by health, College of Nursing (MC 802), 845 S. Damen Avenue, Chicago, IL 60612.
and so become “health-related” (Guyatt, Feeny, & Patrick, E-mail: cferrans@uic.edu
Accepted for publication August 17, 2004.
1993).

336 Fourth Quarter 2005 Journal of Nursing Scholarship

 Health-Related Quality of Life

Characteristics of Individual and Environment tion. Although developmental status is not a static variable,
it cannot be changed or altered by interventions. Neverthe-
Characteristics of individual and environment were in- less, interventions designed to change or modify behavior
cluded in Wilson and Cleary’s original model, but were require consideration of an individual’s developmental sta-
not discussed in the text. Our revised model is based on tus. For example, women with young children and little time
the ecological model of McLeroy and colleagues (McLeroy, for structured exercise programs might be receptive to learn-
Bibeau, Steckler, & Glanz, 1988), as modified by Eyler ing ways to enhance their daily activities at home and work
et al. (2002), to explicate the multiple layers of influence on to reap the cardiovascular benefits (biological function).
health outcomes at both individual and environmental lev- Psychological factors are dynamic, modifiable, and re-
els in HRQoL. McLeroy and colleagues’ model indicates five sponsive to interventions. Cox (1982, 2003) identified cog-
levels of influence: (a) intrapersonal factors (characteristics nitive appraisal, affective response, and motivation as dy-
of individual), (b) interpersonal factors (formal and informal namic intrapersonal factors. Cognitive appraisal includes
social support systems), (c) institutional factors (organiza- factors such as knowledge, beliefs, and attitudes toward an
tions such as schools and healthcare facilities), (d) commu- illness, treatment, or behavior. Affective response is the emo-
nity factors (relationships among institutions and informal tion evoked including anxiety, fear, sadness, or joy. Accord-
social networks in a defined area), and (e) public policy (lo- ing to Cox’s conceptualization, motivation is based on the
cal, state, and national laws and policies). For our revised theory of self-determination (Ryan & Deci, 2000), which
model, everything other than the individual level is consid- distinguishes between different types of motivation arising
ered an environmental influence. Thus, of McLeroy and col- from different reasons for performing a given activity. Intrin-
leagues’ five levels, intrapersonal factors are individual char- sic motivation refers to starting and maintaining a behavior
acteristics and the remaining four levels are environmental because of its inherent enjoyment or satisfaction. It occurs
characteristics. on the basis of a sense of autonomy or self-initiation and
choice. Extrinsic motivation for engaging in a behavior is
determined by the rewards externally provided rather than
by the feelings the behavior engenders, and thus it occurs in
Characteristics of the Individual
environments instead of by individual choice.
In accordance with Eyler et al. (2002), characteristics of
These dynamic psychological factors can influence one an-
the individual in our revised model are categorized as demo-
other. For example, a woman who has a lipoprotein level
graphic, developmental, psychological, and biological fac-
placing her at risk for cardiovascular disease, and who has
tors that influence health outcomes. Thus, we have added
been overweight and sedentary most of her life, might recall
an arrow from characteristics of the individual to biological
the humiliation she experienced in high school when forced
function. Epidemiological evidence indicates links between
to participate in sports. This thought process results in anx-
individual characteristics and biological function, by iden-
iety (affective response) and lack of motivation to change
tifying attributes or behaviors that increase or decrease the
her lifestyle in response to her increased cardiovascular risk.
likelihood of developing a given health problem. Biological
Another woman at risk for cardiovascular disease might re-
factors include body mass index, skin color, and family his-
gard walking as an activity within her capability, giving her
tory related to genetically linked disease and disease risk.
the initial motivation to begin to change her lifestyle. Her
Demographic factors that commonly have been linked to
motivation might stem from learning (cognitive response)
the incidence of illness are sex, age, marital status, and eth-
that physical activity provides cardiovascular benefits, such
nicity. Although these personal characteristics are relatively
as walking at moderate levels.
unchangeable, they are useful for targeting interventions for
specific groups. Targeting requires taking into account the
subgroup characteristics in order to design group-level in- Characteristics of the Environment
terventions (Kreuter & Skinner, 2000). For example, data For the revised model, characteristics of the environment
from the National Health Interview Survey indicated that are categorized as either social or physical, in accordance
African American women have a high prevalence of diabetes, with Eyler et al. (2002). Social environmental character-
increasing with age (American Heart Association [AHA], istics are the interpersonal or social influences on health
2005). In addition, they have higher rates of obesity and outcomes, including the influence of family, friends, and
lower levels of physical activity than do White American healthcare providers (McLeroy et al., 1988). For example,
women, which further increase the risk for diabetes and car- significant others can have a strong influence over when
diovascular disease (AHA, 2005). Thus, these biological and and where health care is sought and whether treatment is
demographic factors give direction to healthcare providers adhered to. The effect of this social environment is signifi-
in targeting whom to screen for health problems such as di- cantly influenced by an individual’s cultural heritage, which
abetes, as well as the types of behaviors to target to decrease can affect participation in preventive care as well as treat-
risk. ment. For example, several studies have indicated that Ko-
Developmental status is also an individual characteristic rean women have much lower rates than do White women in
that is particularly important to consider when explaining participation in clinical breast examinations and mammog-
health behavior and its resultant effect on biological func- raphy (Chen, Diamant, Kagawa-Singer, Pourat, & Wold,
Journal of Nursing Scholarship Fourth Quarter 2005 337
Health-Related Quality of Life

Figure. Revised Wilson and Cleary model for health-related quality of life. Adapted from “Linking Clinical Variables with
Health-Related Quality of Life: A Conceptual Model of Patient Outcomes,” by I.B. Wilson and P.D. Clearly, 1995. Copyright by
JAMA. Used with permission.

2004; CDC, 1997). Korean immigrant women with physi- influenced by characteristics of both individuals and envi-
cians of the same ethnicity have been found to be less likely ronments. Second, the original model included nonmedical
to have a mammogram than were those with non-Korean factors as an independent influence on overall quality of
physicians (Juon, Kim, Shakar, & Han, 2004). Also, Ko- life. We chose to delete this box, because all nonmedical fac-
rean immigrant women have reported that the emphasis on tors can be categorized as characteristics of either individual
their roles as mothers in their cultural tradition did not allow or environment, which already were included in the model.
them to meet their own needs (Im & Cloe, 2001). Third, in the original model many of the arrows were labeled
Physical environment characteristics are those settings by examples. The examples tended to restrict characteriza-
such as the home, neighborhood, and workplace that in- tion of the relationships. Because comprehensive labeling of
fluence health outcomes either positively or negatively. For relationships would be unwieldy, we decided to omit labels
example, neighborhoods with walking and bicycle trails, on the arrows entirely in the revised model.
health clubs, and sports fields are more conducive to physi-
cal activity. In contrast, communities that have a high crime
rates, poor policing, and high levels of pollution have envi- Biological Function
ronments that are not conducive to physical activity. According to the model, biological function (originally
called biological and physiological variables) includes the
dynamic processes that support life. Biological function is
Revisions of the Model viewed broadly and encompasses molecular, cellular, and
whole organ level processes. It can be described as a contin-
Our revision of Wilson and Cleary’s (1995) model of uum of ideal function on one end and serious life-threatening
HRQoL is shown in the Figure. Our primary focus was pathological function at the other end. Alterations in biolog-
the five boxes in the center of the model, which are five ical function directly or indirectly affect all components of
types of measures of patient outcomes. First, biological func- health, including symptoms, functional status, perceptions
tion (originally biological and physiological variables) is de- of health, and overall quality of life. Optimizing biological
scribed as focusing on the function of cells, organs, and or- function is an integral part of holistic care.
gan systems. Biological function would be assessed through The revised model indicates the effects of individual
such indicators as laboratory tests, physical assessment, and and environmental characteristics on biological functioning,
medical diagnoses. Second, symptoms (originally symptom which was not in the original model. The interaction of in-
status), refers to physical, emotional, and cognitive symp- dividual and environmental characteristics also influences
toms perceived by a patient. Functional status, the third biological function.
component, is composed of physical, psychological, social, Effect of individual characteristics on biological function.
and role function. Fourth, is general health perceptions, Individual characteristics influence a person’s biological vul-
which refers to a subjective rating that includes all of the nerability and resilience. Individual genetic characteristics
health concepts that precede it. Fifth, overall quality of life, is influence biological functioning in congenital and hered-
described as subjective well-being, which means how happy itary diseases such as cystic fibrosis and sickle cell
or satisfied someone is with life as a whole. The arrows anemia. Genetic composition predisposes people to the
indicate the dominant causal associations. Reciprocal rela- development of many diseases, including inflammatory,
tionships might exist, but are not characterized in the figure. degenerative, metabolic, and neoplastic diseases. Psycho-
The original model was revised in three substantive ways. logical characteristics, knowledge, and attitudes influence
First, we added arrows to show that biological function is choices people make about lifestyle, ultimately affecting

338 Fourth Quarter 2005 Journal of Nursing Scholarship

 Health-Related Quality of Life

biological function. For example, self-efficacy for exercise Nerenz, 1980) is one theory focused on a person’s somatic
influences exercise behavior and ultimately affects aerobic sensation and the process used to attribute the sensation to
fitness and biological function. illness, external life stressors, or benign sensations. People
Effects of environmental characteristics on biological experience sensations and cognitively process the sensations
function. Physical and social factors in the environment with the background of previous somatic experiences and
affect biologic function. For example, exposure to pathogens with information from the environment. The person’s cogni-
in the environment can cause infectious diseases, and living tive representation of the symptom includes thoughts about
in a high crime community can lead to traumatic injury. its possible identity (heart attack, pulled muscle, influenza),
Effects of interactions between individual and environ- cause, consequence, progression, and cure. The experience,
ment. The emerging field of genomic science illustrates the evaluation, and interpretation of symptoms are part of the
effects of individual environment interactions on biologic characteristics of the individual and the environment. For
function. Genomics is the study of the functions and inter- example, Cameron, Leventhal, & Leventhal (1995) found
action of all genes in the genome (Guttmacher & Collins, in a longitudinal study of community-dwelling middle-to-
2002), and the interaction of genes and environmental fac- older aged adults that people who experienced symptoms
tors as it applies to the expression of common disorders, combined with other stressful events reported more nega-
such as Alzheimer’s disease, colorectal cancer, breast cancer, tive mood states, rated the symptoms as more serious, re-
and AIDS. For example, because of the gene-environment ported more distress about the symptoms, and experienced
interaction some life-long smokers develop chronic obstruc- more disruption of daily activities than did people who expe-
tive lung disease or lung cancer, but others do not. Because rienced symptoms without the presence of stressful events.
genetic characteristics cannot be altered, clinical interven- Thus the experience, evaluation, and interpretation of symp-
tions are directed toward modifying behaviors to reduce the toms are influenced by complex interactions with both in-
risk of disease. dividual factors (such as knowledge and personality char-
acteristics) and environmental factors (such as interactions
with healthcare providers).
Symptoms
Wilson and Cleary (1995, p. 61) indicated that moving
attention from the biological and physiological variables to Functional Status
symptom variables requires a shift focus from cellular and Wilson and Cleary (1995) defined functional status
organism level to a person level. They define symptoms as broadly, as the ability to perform tasks in multiple do-
“a patient’s perception of an abnormal physical, emotional, mains such as physical function, social function, role func-
or cognitive state,” which can be categorized as physical, tion, and psychological function. Functional status can be
psychological, or psychophysical. viewed from various perspectives. Traditional models per-
Instruments to measure symptoms can be classified as tain to functional status from the perspective of disabil-
global measures, condition-specific measures, and symptom- ity or disablement, focused on the loss of function and
specific measures. Global measures are broad and include its effects on daily life (Stineman et al., 2005). Alterna-
many varied symptoms. The Symptom Impact Inventory tively, in the revised model we view functional status by
is an example of a global measure (Miller, Wilbur, Mont- focusing on optimization of the function that remains.
gomery, Chandler, & Bezruczko, 2001). Condition-specific Leidy’s (1994) framework for functional status is an exam-
measures are focused on the symptoms associated with a par- ple of this perspective and it is a useful guide for health
ticular condition and include the Chronic Respiratory Dis- care.
ease Questionnaire (Guyatt, Berman, & Townsend, 1987) According to Leidy’s framework, functional status in-
and the Unstable Angina Symptom Questionnaire (DeVon cludes four dimensions: functional capacity, functional per-
& Zerwic, 2003). Symptom-specific measures pertain to a formance, functional capacity utilization, and functional re-
particular symptom, such as fatigue as measured with the serve (Leidy, 1994). Functional capacity is defined as one’s
Piper Fatigue Scale (Piper et al., 1989) or anxiety and depres- maximal capacity to perform a specific task in the phys-
sion as measured with the Hospital Anxiety and Depression ical, social, psychological or cognitive domains. For ex-
Scale (Zigmond & Snaith, 1983). ample, functional capacity might be one’s maximal ability
The most common dimensions of symptoms that are mea- in strength and endurance or in aptitude or memory. The
sured include frequency, intensity, and distress. Other di- second dimension, functional performance, refers to activ-
mensions that have been incorporated in symptom measures ities that one performs on a day-to-day basis. Functional
include quality, cause, treatment, consequences, location, performance is an integrated response and is determined
and timing. Instruments vary on which dimensions are in- by multiple factors, including personal choice, values, and
cluded and several dimensions might be included in the same motivation. Functional performance could be assessed by
instrument. the level of physical activity and energy expended or as
A variety of theories are focused primarily on symptoms. self-reported activities across multiple categories. Alterna-
The Common Sense Model of Illness (Leventhal, Meyer, & tively, functional performance could be measured by daily

Journal of Nursing Scholarship Fourth Quarter 2005 339

Health-Related Quality of Life

memory performance. Functional performance also could of the decline in day-to-day activities also could be influ-
be influenced by functional capacity, as in cases when re- enced by individual characteristics, such as self-efficacy and
duced capacity limits performance of day-to-day activities. motivation for physical activity, or by social environmen-
The third dimension, capacity utilization, refers to the per- tal factors, such as social support for physical activity and
centage of functional capacity that is used day to day. The community safety.
fourth dimension, functional reserve, refers to the difference
between capacity utilization and functional capacity. People
General Health Perceptions
generally do not function at 100% of their capacity on a
Wilson and Cleary (1995) pointed out two defining char-
day-to-day basis, and people with high capacity might ac-
acteristics of general health perceptions: (a) they integrate all
tually use only a small percentage of their capacity daily.
the components that come earlier in the model, and (b) they
When functional capacity declines because of health prob-
are subjective in nature. This component is a synthesis of all
lems, a person might be required to use a higher percentage
the various aspects of health in an overall evaluation. Sup-
of capacity or to cut back on daily activities. Capacity uti-
porting this idea is the finding that the strongest and most
lization is closely related to functional reserve and indicates
consistent predictors of general health perceptions are phys-
the unused potential. People with low capacity and very low
iological processes, symptoms, and functional ability, based
functional performance could have a fairly large functional
on a review of 39 studies of the general population (Bjorner
reserve.
et al., 1996). Although general health perceptions are influ-
Measures of functional capacity have been widely re-
enced by the earlier components of the model, they never-
ported in the scientific literature, and many established mea-
theless are different from the others. Thus using measures
sures of this dimension are available. For example, the maxi-
of other components, such as functioning or symptoms, to
mal oxygen uptake is a measure of aerobic capacity and is as-
assess general health perceptions is not appropriate. Instead,
sessed during a symptom-limited exercise test. The 6-minute
this component is most commonly measured with a single
walk test and the shuttle walk test are used to measure func-
global question to ask people to rate their health on a Lik-
tional capacity for walking. Similarly, tests of skeletal mus-
ert scale ranging from poor to excellent. Ratings of general
cle strength indicate functional capacity for strength. The
health perceptions are used both as single-item measures and
measurement of functional performance is less advanced.
items in a battery, as in the SF-36 Health Survey (Ware &
One commonly used measure of functional performance is
Sherbourne, 1992).
the Functional Performance Inventory (FPI). Leidy (1999)
When rating their health, people typically consider various
developed the FPI with people who had COPD; it has the
aspects of their health, as well as the implicit importance of
potential to be appropriate for other groups of people with
each. Further, men and women differed systematically when
chronic illness, such as chronic congestive heart failure. In
evaluating their health in general (Benyamini, Leventhal, &
addition, two scales from the SF-36 Health Survey (Ware
Leventhal, 2000). Men’s health ratings pertained to seri-
& Sherbourne, 1992) have been used widely to measure
ous, life-threatening diseases (such as cardiac disease), but
functioning: the physical functioning and social function-
women’s health ratings included both life-threatening and
ing scales. The SF-36 is a generic measure that can be used
nonlife-threatening disease (such as arthritis). In addition,
with both healthy people and people with chronic illness.
gender differences were found in the effect of negative emo-
Many investigators also have used the Sickness Impact Pro-
tion on general health ratings. For men emotion was linked
file to measure functional performance, but it is an indirect
primarily to serious disease, and for women it was linked to
measure of functional performance and a direct measure of
a wider variety of life factors.
functional impairment.
No instruments are established for the measurement of ca-
pacity utilization and functional reserve. Although the con- Overall Quality of Life
cepts of capacity utilization and functional reserve are not Overall quality of life, the final component of the model,
readily measured objectively, they are clinically meaningful was characterized by Wilson and Cleary (1995) as subjective
and could be measured subjectively. well-being related to how happy or satisfied someone is with
In the revised HRQoL model, multiple factors can affect life as a whole. Over the past 30 years the concept of subjec-
functional status. For example, functional capacity can be tive well-being has developed considerably as a general area
directly affected by biological function and by symptoms, of scientific interest (for a comprehensive review, see Diener,
and functional performance can be affected by characteris- Suh, Lucas, & Smith, 1999). Subjective well-being does not
tics of the individual and the environment. In people with represent a single construct; it includes pleasant and unpleas-
COPD, functional capacity can be limited by ventilatory ca- ant affect, global judgments of life satisfaction, and satisfac-
pacity and by symptoms of dyspnea or leg fatigue. How- tion with individual domains of life (Diener et al., 1999).
ever, symptoms alone do not fully account for the decrease The number of life domains varies among authors, depend-
in functional capacity. If symptoms are severe enough, they ing on the desired level of generality. At a broad level of
might interfere with day-to-day levels of activity, which abstraction, the domains have been characterized as health
might cause a patient to become sedentary and physically and functioning, psychological and spiritual, family, social,
deconditioned (decline in functional status). But the extent and economic (Ferrans, 1990, 1996). This characterization

340 Fourth Quarter 2005 Journal of Nursing Scholarship

 Health-Related Quality of Life

is consistent with prevailing views of the domains of qual- identification of domains has not remedied the problem of
ity of life in the literature, although the specific terminology conceptual confusion, nor has narrowing the field to vari-
varies somewhat among authors (Ferrans, 2005). ables that are “health related.” Lack of precision in termi-
Many theories and conceptual models have been pro- nology about quality of life has resulted in the use of same
posed to explain the components of subjective well-being. terms to mean different things. The current need is for mod-
Campbell, Converse, and Rodgers (1976) published one of els to clarify the critical elements of HRQoL and the causal
the earliest and most influential reports to characterize the relationships among them.
determinants of life satisfaction. They described the rela- Wilson and Cleary’s model (1995) includes a useful taxon-
tionship between the characteristics of the individual and omy of the variables that commonly have been used to mea-
environment and the level of life satisfaction experienced. sure HRQoL. Although the model was published in 1995,
In their model, life satisfaction is determined by the person’s it has not been widely used. We revised their original model
evaluation of attributes of various domains of life. This eval- in three substantive ways: (a) adding arrows to show that
uation is dependent on the person’s perception of attributes, biological function is influenced by characteristics of both
as well as internal standards by which those perceptions are individuals and environments, (b) deleting nonmedical fac-
judged. Internal standards include personal values, expec- tors, and (c) deleting the labels on the arrows because they
tation levels, aspiration levels, personal needs, and compar- tended to restrict characterization of the relationships. We
isons with others. Individual perception is influenced by per- also provided theoretical background for each of the major
sonal characteristics, such as demographic characteristics, components of the model and examples of instruments for
general optimism or pessimism, as well as other attributes of measuring them. The result is a revised model to advance
personality. knowledge and use of the concept of HRQoL in nursing
In concordance with Campbell et al. (1976), Wilson and and health care.
Cleary (1995) emphasized how patients’ values and prefer-
ences affect overall quality of life. Because of differences in
values, an impairment that makes life not worth living for References
one person might be considered only a bother for another.
For this reason, the importance of values should be part of American Heart Association. (2005). Heart disease and stroke statistics
an assessment of satisfaction with life. Life satisfaction can 2005 Update. Dallas, TX: Author.
be measured through a single global question, asking how Benyamini, Y., Leventhal, E.A., & Leventhal, H. (2000). Gender differ-
ences in processing information for making self-assessments of health.
satisfied the person is with life in general, or through a series Psychosomatic Medicine, 62, 354-364.
of questions about satisfaction with various aspects of life. Bjorner, J.L., Kristensen, T.S., Orth-Gomer, K., Tibblin, G., Sullivan, M.,
If scores on a series of questions are simply summed, then & Westerholm, P. (1996). Self-rated health: A useful concept in research,
each aspect of life is given equal value. However, some in- prevention, and clinical medicine. Stockholm: Forskningsradsnamnden.
Cameron, L., Leventhal, E.A., & Leventhal, H. (1995). Seeking medical
struments include a weighting system to allow for differences care in response to symptoms and life stress. Psychosomatic Medicine,
in importance for each aspect of life, and thus would indicate 57(1), 37-47.
differences in values of respondents. Two examples are the Campbell, A., Converse, P.E., & Rodgers, W.L. (1976). The quality of
American life: Perceptions, evaluations, and satisfactions. New York:
Quality of Life Inventory (Frisch, 1993) and the Quality of
Russell Sage Foundation.
Life Index (Ferrans & Powers, 1992; Ferrans, 1990). Mea- Centers for Disease Control and Prevention. (1997). Behavioral risk fac-
suring the importance of various aspects of life also has an tor survery of Korean Americans—Alameda county, California, 1994.
additional advantage. Recently, concern has been expressed Morbidity and Mortality Weekly Report, 46(33), 774-777.
Chen, J.Y., Diamant, A.L., Kagawa-Singer, M., Pourat, N., & Wold, C.
about the effect of “response shift,” which is a change in (2004). Diaggregating data on Asian and Pacific Islander women to as-
internal standards and values in response to significant life sess cancer screening. American Journal of Preventive Medicine, 27(2),
events. These changes can occur as a result of cognitive, af- 139-145.
fective, and behavioral processes used to accommodate to Cox, C.L. (1982). An interaction model of client health behavior: Theoret-
ical prescription for nursing. Advances in Nursing Science, 5(1), 41-56.
illness (Sprangers & Schwartz, 1999). The implication is Cox, C.L. (2003). Online exclusive: A model of health behavior to guide
that changes in instrument scores might sometimes indicate studies of childhood cancer survivors [electronic version]. Oncology
changes in internal standards, rather than in the attribute Nursing Forum, 30(5), E92-E99.
of interest. A benefit of using an instrument to measure pa- DeVon, H.A., & Zerwic, J.J. (2003). The symptoms of unstable angina: Do
women and men differ? Nursing Research, 52(2), 108-118.
tients’ values is that it allows the investigator to determine Diener, E., Suh, E.M., Lucas, R.E., & Smith, H.L. (1999). Subjective well-
whether values have changed over the course of the study. being: Three decades of progress. Psychological Bulletin, 125(2), 276-
If changes have occurred, they then can be accounted for in 302.
the statistical analysis. Eyler, A.E., Wilcox, S., Matson-Koffman, D., Evenson, K.R., Sanderson,
B., Thompson, J., et al. (2002). Correlates of physical activity among
women from diverse racial/ethnic groups. Journal of Womens Health
and Gender Based Medicine, 11(3), 239-253.
Conclusions Ferrans, C.E. (1990). Development of a quality of life index for patients
with cancer. Oncology Nursing Forum, 17(3), 15-19.
Ferrans, C.E. (1996). Development of a conceptual model of quality of life.
Identification of the domains of quality of life is an impor- Scholarly Inquiry for Nursing Practice: An International Journal, 10(3),
tant task that has been reasonably accomplished. However, 293-304.

Journal of Nursing Scholarship Fourth Quarter 2005 341

Health-Related Quality of Life

Ferrans, C.E. (2005). Definitions and conceptual models of quality of Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common sense rep-
life. In J. Lipscomb, C.C. Gotay, & C. Snyder (Eds.), Outcomes assess- resentation of illness danger. Contributions to Medical Psychology, 2,
ment in cancer (pp. 14-30). Cambridge, England: Cambridge University 7-30.
Press. McLeroy, K.R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological
Ferrans, C.E., & Powers, M. (1992). Psychometric assessment of the perspective on health promotion programs. Health Education Quarterly,
Quality of Life Index. Research in Nursing and Health, 15, 29- 15(4), 351-377.
38. Miller, A., Wilbur, J., Montgomery, A., Chandler, P., & Bezruczko, N.
Frisch, M.B. (1993). The Quality of Life Inventory: A cognitive-behavioral (2001). Measurement properties of the symptom impact inventory. Jour-
tool for complete problem assessment, treatment planning, and outcome nal of Outcome Measurement, 4, 763-793.
evaluation. Behavior Therapy, 16, 42-44. Piper, B., Lindsey, A., Dodd, M., Ferketich, S., Paul, S., & Weller, S. (1989).
Guttmacher, A.E., & Collins, F.S. (2002). Genomic medicine—a primer. The development of an instrument to measure the subjective dimen-
New England Journal of Medicine, 347(19), 1512-1520. sion of fatigue. In S.G. Funk, E.M. Tornquist, M.T. Champagne, L.A.
Guyatt, G.H., Berman, L.B., & Townsend, M. (1987). A new measure Copp, & R. Wiese (Eds.), Key aspects of comfort (199–208). New York:
of quality of life for clinical trials in chronic lung disease. Thorax, 42, Springer.
773-778. Ryan, R.M., & Deci, E.L. (2000). Intrinsic and extrinsic motivations: Clas-
Guyatt, G.H., Feeny, D.H., & Patrick, D.L. (1993). Measuring health- sic definitions and new directions. Contemporary Educational Psychol-
related quality of life. Annals of Internal Medicine, 118(8), 622- ogy, 25, 54-67.
628. Sprangers, M.A.G., & Schwartz, C.E. (1999). Integrating response shift
Im, E.O., & Choe, M.A. (2001). Physical activity of Korean immigrant into health-related quality of life research: A theoretical model. Social
women in the US: Needs and attitudes. International Journal or Nursing Science and Medicine, 48, 1507-1515.
Studies, 38, 567-577. Stineman, M.G., Lollar, D.J., & Ustun, T.B. (2005). International classi-
Juon, H.S., Kim, M., Shankar, S., & Han, W. (2004). Predictors of ad- fication of functioning, disability, and health: ICF empowering rehabil-
herence to screening mammography among Korean American women. itation through an operational bio-psycho-social model. In J.A. DeLisa
Preventive Medicine, 39(3), 474-481. (Ed.), Physical medicine and rehabilitation principles and practice (pp.
Kreuter, M.W., & Skinner, C.S. (2000). Tailoring: What’s in a name? Health 1099-1108). Philadelphia, PA: Lippincott, Williams, & Wilkins.
Education Research, Theory, and Practice, 15, 1-4. Ware, J. , Jr., & Sherbourne, C.D. (1992). The MOS 36-item short-form
Leidy, N.K. (1994). Functional status and the forward progress of merry- health survey (SF-36). Medical Care, 30, 473-483.
go-rounds: Toward a coherent analytical framework. Nursing Research, Wilson, I.B., & Cleary, P.D. (1995). Linking clinical variables with health-
43(4), 196-202. related quality of life: A conceptual model of patient outcomes. JAMA,
Leidy, N.K. (1999). Psychometric properties of the Functional Performance 273(1), 59-65.
Inventory in patients with chronic obstructive pulmonary disease. Nurs- Zigmond, A.S., & Snaith, R.P. (1983). The hospital anxiety and depression
ing Research, 48, 20-28. scale. Acta Psychiatrica Scandinavica, 67, 361-370.

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